Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Tuesday, September 30, 2008

______________Okay, I'm going to add one more thought and then I'll shut up. Borderline Personality Disorder is a condition that includes "affective (=mood) instability" and the differentiation between a personality disorder and a mood disorder can be difficult even for experienced psychiatrists.

...raised another question which is: Is there any one or two key symptoms/behaviors that clearly differentiate Borderline Personality Disorder from any one of the mood disorders?_____________________Great question. Easy Answer: No.

Okay, but you inspired a post, so I'll elaborate. How does a psychiatrist differentiate, sometimes unsuccessfully, the diagnostic quandary of mood disorder versus borderline personality disorder? They both entail mood instability and behavioral indiscretions, especially impulsive behaviors during manic and hypomanic episodes, and the results of these illnesses can both result in chaotic lives.

So in my shrinky mind, I'll start with the issue of chronicity and overall quality of life. Someone's trekking along just fine (it doesn't matter when or for how long).... they have a life pattern of being able to work and to love, and suddenly they get zapped with a depression and things start falling apart-- they don't want to socialize, they don't want to work. At some point, with or without treatment, the episode ends and they go back to their regular old life. This person doesn't have borderline personality disorder, they have had an episode of depression. Oh, but we've already said that there a people with chronic depressions which are less easily defined into distinct episodes, and it appears their may be people with bipolar disorder, especially bipolar disorder type II, who spend much of their time cycling into and out of depressions and hypomanias, and they all kind of blur together. The chaos of it all is rather disruptive, and during these not-quite discrete episodes of hypomania, they engage in all sorts of impulsive behaviors: promiscuity, drug use, indiscriminate spending, gambling, fighting.

Simply put, if life is a constant episode of chaotic behavior, if the patient is unable to maintain employment, is often the center of dramatic upheavals regarding interpersonal relationships ( or drama with everything else), if the patient can't maintain some semblance of romantic relationships or friendships and is always struggling with co-workers and employers, then a psychiatrist is going to label this a personality disorder. And to be totally blunt, if this same patient repeatedly threatens suicide in a way that garners the troops, or cuts themselves because it relieves psychic pain, then a psychiatrist will label this Borderline Personality Disorder. If the patient is repeatedly painting pictures of people in black and white-- one moment someone is all good, the next they are all bad, or everyone is one color with no shades of gray, and if he manages to frequently pit the people in his life against one another, well, a psychiatrist is still going to label this Borderline Personality Disorder. Good or bad, right or wrong, that's currently how it goes. The label has a pejorative edge, as if the patient should just grab hold of themselves and stop doing this. These patients often are difficult to deal with, they ask a lot of their physicians and they often get angry at the docs who are trying hard to help them. They may push up against the shrink in such a way that the shrink gets uncomfortable, feels a need to set up clear boundaries, and these boundaries feel rejecting to the patient, who now has one more data point in seeing how everyone is mean to them. The patient may well not see that they had a role in inspiring the reaction. "I need you..." their behavior says, " and you shouldn't be pushing me away." There may be little insight that they are asking too much, that the shrink feels overwhelmed, over-wanted, pushed against the wall in uncomfortable ways.And the other issue, not for today, is that sometimes psychiatrists label people they don't like with personality disorders rather than taking a careful look at their own roles in interactions that struggle. Diagnostically, the label is a vague one, and it means more than an isolated personality clash...again, for another day.

So the chronic, chaotic, interpersonal issues point more towards a personality disorder than a mood disorder. Self-mutilating behavior (as opposed to suicidality) is not a symptom of mood disorders. And while people with manias may wreak all sorts of havoc, it's an episode, not a lifestyle.

So here's the next question: Does it matter?

There are mood disorder experts out there who will say that if you take people with these chaotic stories, re-think them as having chronic and rapid-cycling mood disorders, and treat them with medications to stabilize their mood, they do better and sometimes the chaos calms down.

There are personality disorder experts out there who say they've never met anyone with borderline personality disorder who doesn't, at least episodically, have a co-morbid mood disorder.

So, I suppose if you're going to say it's Borderline Personality Disorder and the only treatment is long-term intensive psychotherapy and there's no role for even trying medications or considering the possibility of addressing issues of mood or anxiety, then perhaps the treatment options have been kept narrow and uncreative. If therapy alone isn't helping, the patient might consider another opinion. And if meds alone aren't working, then maybe some therapy is in order.

43
comments:

Great explanation to a very complex diagnosis. My mom was diagnosed bipolar ten years ago, and borderline four years ago. Both fit, but the bpd diagnosis explains a lot of her bizarre behavior over the years.

I am not a slut, I generally don't drink and I don't do and have NEVER done any illegal drugs.

I'm just going to compose this stream-of-consciousness style because I'm sure that it won't take a genius to see some problems with my thinking.

I love and hate my psychiatrist. I want him to be my daddy and to hold me and tell me I'm a "good girl." I want to stab him in the chest with a Samurai sword.

I hate waking up each day and I hate my job. I am always bored. I have no social life. I was married almost 20 years, but finally got out of my unsatisfying marriage 2 years ago. I don't want any relationships. They create demands that my depression probably won't allow me to meet.

I am fascinated with psychiatry but angry with it. Psychiatrists know everything and NOTHING. They HIDE things and LIE, but they're all I have.

My psychiatrist wants to get rid of me and that is why he referred me to someone closer that takes my insurance because I can't afford my $200 non-netwok shrink.

I hurt badly, everyday.

I enjoy nothing...not true, I love my dog, but I know I don't deserve her.

All I want to do is sleep.

Lately, I think about killing myself A LOT. I haven't cut myself in quite awhile, but I feel like I need to. I need to punish myself. I feel like I need to see some blood and hurt because I am a horrible person.

I wish I could just donate my organs so I could be of some use in this world. All my dreams are dead and I can't bounce back anymore.

Sleeping is the best part of my life.

Lily

PS I don't call my shrink a lot. All he will say if I am suicidal is blah blah blah, go to hospital. No way. I have called the Hopeline once and my EAP once for suicidality and that's it. I have had three suicide attempts, but over 15 years ago.

I envy my psychiatrist's children. I made the mistake of asking him where he got a teddy bear that was on his window silland he said his son. He lit up when talking about his kids. I felt a jealousy that I'd never felt before. I know that my Dad's eyes would never light up when talking about me. The birthday present I got him is on the floor in the closet. He didn't even remember mine.

I telll myself to GROW UP! I am feeling so much lately. Anger, destructiveness, combativeness. I was in therapy for 5 years. I quit because I didn't see results and because therapist kind of made me uncomfortable by patting my back after sessions, outside the office. I feel like an idiot. I think he was a good therapist.

I don't know who I am or what I am. I don't want to switch docs again. I don't know if he's helping or what. If I need to be more interesting I can do that.

Wow, that was extremely informative. I've wondered about Borderline Personality Disorder for a long time because it gets over-dramatized in media and stuff.

Actually, your explanation of Borderline exactly described a close relative of mine. Of course, no one in my family besides myself would seek psychological help -- I have an anxiety disorder and depression. There's a question: how do you encourage someone to seek help when the person absolutely refuses? Is it even possible?

I can probably answer my own question as I did not go into psychotherapy until I realized I was so depressed and anxious I just couldn't function. Still, it would be nice if there was something I could do to help family members who really need counseling or something.

Borderline Personality Disorder is viewed so pejoratively in the psychiatric system that I don't diagnose it unless I am absolutely sure, that is, it is a classic case and I have observed someone over time. The supposed empowerment resulting from a BPD diagnosis has to be pretty major (and sometimes it is, for textbook cases) to outweigh the stigma.

I tend to distinguish between "affective" and "dynamic" borderlines. The former come closest to bipolar II as you describe it. The latter engage in specific behaviors that have much more social meaning and that reflect a disabled self, such as fear of aloneness/abandonment, splitting, and emotional manipulation.

As this diagnostic controversy shows, our need for labels (a need on the part of both psychiatrists and patients) and a need for categories (any categories!) to guide research exceed any certainty, still, that these constructs correspond to anything that's really out there.

And what do we end up doing clinically, whether through meds or psychotherapy? When it comes to the nitty gritty of treatment we treat symptoms and syndromes, not "disorders," while the DSM accumulates dust on the shelf.

Thanks for this. Now I REALLY am sure I should get a new shrink. He had no reason to call me borderline other than what must be countertransference (though I basically knew this over my own reading). And honestly, I don't love/hate him, though I'm often angry at him over being a bad shrink and doing things like calling me borderline and then refusing to discuss it. But it gets more and more clear that the problem is him, not me. I don't have any of those things...and interepisode, nothing.

Thanks for the clarification post. And I learned a WHOLE lot about how when a shrink relates to someone in a certain way, they cause the behaviors. After that, I never dealt with a crazy mother in pediatrics again - by making sure that I myself didn't see her as crazy, I reduced the amount of "crazy parent" behavior massively. So I guess I did learn something from all of that.

"Self-mutilating behavior (as opposed to suicidality) is not a symptom of mood disorders."

Could you explain this comment? I know that self-injury (often used interchangeably with "self-mutilation") is most typically associated with borderline personality, but this symptom also seems to show up sometimes particularly in depressed adolescent girls who may or may not also have symptoms of borderline personality disorder.

Also possible that the majority of those who cut themselves to relieve psychic pain AND tell you about it are people who also have other symptoms of borderline personality disorder.

Lily: I'm not sure what to say. Please rest assured that psychiatrists do not know everything. We may know nothing.And I should know more about DBT.

Ester: I'm only aware of ways to force someone into treatment through the legal system if they are an imminent physical danger. Sometimes it helps if one confides that they had a similar problem and treatment was helpful, but that's a personal decision and it doesn't always work.

Anonymous: Insurance only reimburses for the treatment of Axis I disorders, not counting substance abuse.

Novalis: agreed. In my initial evaluations, I note the Axis I disorder, and write Axis II: "deferred"...seems the reasonable thing to do for someone I've just met. My DSM is also dusty.

Sorry for being off-topic, but I couldn't figure out where else to ask: Is Shrink Rap fading away? No podcast for months and no posts from Clink or Roy in weeks. Dinah, great job of keeping the blog active, but what's going on?

What an interesting post. I have been diagnosed as both. I do tend to get very 'borderline' when I have a lot of suicidal feelings. I have been diagnosed as bipolar II only because I have a mood disorder and a father who is bipolar 1. I would rather tell people I am bipolar than borderline.

Anyways, I have not been feeling well. Iam not sleeping well, I am very anxious (my leg bounces alot) and I have had some anxiety attacks (my own term..."almost" panoc attacks).

So...I have new student insurance. I went to the student health psychiatrist. He told me I was on a cocktail of meds that aren't doing anything but getting me fat. He said he wasn't sure if I was either bipolar or borderline.

It is alot to swallow when you are not feeling well, and really need a doctors help.

Anon: Shrink Rap is still here, and so am I. Short answer is: new job, new hobby, no time, no sleep, having too much fun to blog. That and a computer death that just got fixed this weekend. Podcasting this weekend, right bloggers?

Rach, the guy was real, and he actually said that. He was the medical director of a CMHC facility specifically for people in crisis.

He also told me exactly how to kill myself, although he neglected to mention the part about liver failure and lingering in pain for several days while witnessing your family's emotional agony. (No, I'm not going to try it)

Apparently, he has quite a reputation in the psychiatric community, and has been employed by nearly every hospital in town. I have been told he's a narcissist who has difficulty relating both to patients and colleagues.

He's practicing in a different branch of medicine now, one that involves less patient contact.

anonymous: re: self mutilation in depressed adolescent girls without any other symptoms of personality disorder: > I don't know anyone who cuts themselves and has no other symptoms of personality disorder. Then again, I don't treat kids, and it sort of feels to me like all of adolescence is kind of a developmental personality disorder (I am sort of kidding here).

LadyAK47: I hope you feel better soon, same to everyone else who wrote in to say they're feeling lousy.

Glad to hear the people-hating psychiatrist changed professions.

And I thought I meant Reeking Havoc, but apparently I meant Wrecking havoc. Thanks, and I've changed it. Stinks when I do that (reeks, actually)!

I just want to add that I meant nothing derogatory with my "bizarre" behavior comment. As other commenters chime in who suffer from bpd and other illnesses, I would hate for anyone to read my comment and feel like I'm labeling them as "bizarre" or "bad."

Nothing could be further from the truth.

And I will say that with consistent dbt therapy and medication, my mom has shown so much improvement.

I don't believe the person with bpd is the hopeless cause.

Finding a good psych and a good shrink was half the battle with my mom. The other half has been her incredible courage and follow-through and determination to get the help she needs.

I could go on, but I'll stop there. I just really didn't want anyone to misunderstand my comment and feel worse than they do already...

I'd like to encourage anyone with behavioral difficulties, whether they stem from mood or personality disorders, to try DBT. Dialectical Behavior Therapy combines research into the biological and social elements of disorders. It was developed by Marsha Linehan, and first used with people having a high risk for suicide. This was successful. The therapy spread in use to include other levels of Borderline Personality Disorder, and people having multiple problems, including the mood/affect disorders.

This therapy is effective. It is often necessary to include medicinal treatment as well.

This is my story. DBT works. I recently finished a year in a DBT group, combined with individual therapy. Before I started I could leave the house only with my spouse. Now I'm taking 2 classes at a community college. My combination if disorders include MDD, BPD, PTSD, GAD, and something that resembles bipolar - but with the deep depression, the top level of affect is what some one else might call "normal."

I was 24, had had a couple of depressive episodes that i almost managed to hide, had cut on and off, but mostly discreetly. I found the book 'I hate you, don't leave me' by accident in a bookshop, and thought 'thank god, I am not the only loser in the world'.

I self-defined myself as Borderline, almost entirely because of the cutting. When I finally started seeing a pdoc 3 years later that was what I said that I thought I was. Even though I eventually realised that 90% of the symptoms are so blurred that they are irrelevant.

Yes, I am suicidal a lot of the time, but never manipulative about it - mostly no-one even knows. I am useless at serious relationships, but I also avoid people with whom i could actually have one. I have friendships that have lasted for 30 years. I almost never hate people. Everything that I hate myself for is related to being completely depressed. Or occasionally hypomanic....

Except the cutting. I'm 43 now, have cut once this year. There are still times where I really, really want to - but am managing not to.

When current pdoc said BP II, I realised how much more like me that actually is - before him I'd never read much BP I, and I don't do manic, so that was out.

" I don't know anyone who cuts themselves and has no other symptoms of personality disorder. "

When I let my abusive childhood home, I was self-mutilating. I was very confused and ashamed about why it made me feel less detached from everything. I looked for answers in books, read about Borderline, and was terrified that it was my problem. I didn't seek help for my problems for 10 years.

I suppose I may have a personality disorder. My counselor has presented it to me as PTSD. I have a great job and good friends, although no romantic relationships at this point because they scare me. My self-mutilation, now a thing of the past, generally coincided with contact with the abusive person.

I guess I just have a problem with the whole concept of a personality disorder. It makes me feel like who I am is inherently wrong and abnormal, and I heard enough of that growing up. I'd just rather hear my problems cast in a different light.

" I don't know anyone who cuts themselves and has no other symptoms of personality disorder. "

I don't agree with this at all. I have, most definitely Bipolar II. I have cut myself in past manic episodes that swerved into marked dysphoria. Three different psychiatrists have ASSURED me that I injured myself in that mental state because of the bipolar-related dysphoria, and that I do NOT have BPD (absolutely no other markers of BPD in my life).

In short, I think you are making a pretty remarkable generalization here!

The point of my post was to go through how a shrink thinks of personality versus mood disorders, to make the point that the symptoms overlap with those of other disorders: Bipolar, bipolar II, dysthymia, ptsd, ADD, anxiety, and the various other (besides Borderline) personality disorders.

The fact is, "I don't know anyone who cuts themselves and has no other symptoms of personality disorder."

I didn't say, If You Cut, You Have a Personality Disorder , and I really didn't say If You Cut, Then You're a Borderline.

My point was diagnostic fuzzyiness. There are a bunch of personality disorders: line up all the symptoms and find me someone who cuts who doesn't have some of them (even if they can be explained by another diagnosis)-- Okay, actually line up all the symptoms of all the personality disorders and find me a single human being who doesn't have some of them....they're symptoms, they only get called a disorder when the WREAK havoc with someone's life and cause distress!

People with PTSD cut, not all, but many do. PTSDers, may show some symptoms of personality disorder if you are looking only for symptoms and and not causes. PTSD is not a personality disorder despite symptom overlap. Therefore, there are people who cut who do not have a personality disorder, which one can only really have if such dx is gifted to you by a shrink who thinks along those lines.In that situation you are then no different form anyone else except insofar as you have a disorder that is documented on a piece of paper or computer drive. Of course, PTSD is also a construct but it is fascinating how so much personality disorder becomes something that, while as disorder, does not reflect personality defect. Further, docs who do work with the notion of PTSD will tell you that rather than having a disordered personality, you actually have pretty amazing personal resources and strength to have come through the abuse even though you may sometimes cut or do other things. So much has to do with the personal (not talking transference issues) bias of the clinician. So if you have never seen a person who cuts who is not personality disordered, that is nice but be aware that your training, bias and the glasses you have on will all influence what you see.

Im confused. If SI isn't a symptom of mood disorders, what does it mean if the person only cut for a few months (not as suicidal gesture) while diagnosed with adjustment disorder w/ depressed mood?

The doc recommended a BPD support group with the disclaimer that there was only the shared symptom, but if shrinks can't stand 'em then it seemed like someone with possible avoidant PD might rather shoot themselves...so that never happened.

Okay, I didn't see you addressed that question about SI. I'm not really sastisfied with the answer, but that's life.

Also, to those with BPD, I want to apologize for my comment about shrinks not being able to stand those with the disorder. That's merely the impression I got and didn't word it gently. Just trying to emphasize the dislike some people have of people drama, particularly those with other PDs.

The thing that surprises me about Borderline Personality Disorder is that some psychiatrists are so keen to diagnose it in teenage and young adult women who have been suffering symptoms for a fairly short time - a month or two, a year or two at most. Obviously the "long-standing" part of the diagnostic requirements isn't important for these doctors. Also, seeing as there is some evidence that many people diagnosed with BPD actually get better, surely either as a set of diagnostic criteria it's not describing a true personality disorder, or doctors aren't diagnosing correctly. Saying personality disorder to a patient is a bit like saying diabetes, or heart failure, or Alzheimers, or pancreatic cancer - you've probably got this for the rest of your life, mate.

I think one of the most important factors in differentiating between the two is that if the person is better for significant periods in between defined attacks, it's definitely not BPD. But otherwise, it's so fuzzy! If you docs can't even tell whether a problem is Axis I or Axis II, surely there's a problem with the diagnostic system of axes (um - that is, more than one axis, not sharp hacky things) and incurable personality disorders. If I were a psychiatrist I think I would use the borderline diagnosis as little as possible, if at all.

BTW there may be a cutting problem coming to your adult practice soon - when I was in an adolescent psychiatric hospital a few years ago almost every patient cut, no matter what the diagnosis, and I doubt these problems are going to disappear when they hit 18. At least two of my friends at school cut. It's a pretty common thing in my generation - BPD can't be getting that common!

Just wanted to add that the time course of the emotional lability symptoms is a big part of the differential-- Most people with BPD will report that mood shifts happen for hours, not days and almost never a week or more. Also, the mood shifts in BPD are tied to environmental stimuli, so there is a clear cue, whereas in Bipolar the shift is more out of the blue.

my gp who has known me for 5 years said i had bipolar sent me to see a shrink and she said after seeing me for only 6 minutes that nope you are borderline now i dont have a clue or know what to do or think help anyone

Conclusions: Self-mutilation and suicide attempts are only partially overlapping behaviours, although both are predicted by mood disorder diagnosis and harm avoidance. Self-mutilation has a particularly strong association with bipolar disorder. Clinicians need to think of bipolar disorder, not borderline personality disorder, when assessing an individual who has a history of self-mutilation.

I really wish that people would stop referring to themselves as "borderlines" or "bipolar" and that doctors would stop referring to their patients that way. It is so dehumanizing. People are people with disorders. People are not disorders. Jane HAS borderline personality disorder. Jane is NOT "borderline" or "a borderline." Joe HAS bipolar disorder. Joe is NOT "bipolar." How we speak about ourselves and our patients (in the case of physicians) affects how we perceive ourselves and our patients. This is an ongoing pet peeve of mine that I'm sure I'll never be able to change on a widespread basis, but I thought I'd comment on it here. Thank you for allowing me to do so.

I really do not care what I have anymore...Bipolar label makes me feel defective and Borderline label makes me feel like I'm some sort of evil psycho....I just want to finally be happy, function normally, and be able to give love as well as get it. I will just say this...as suffers of mental health issues, often times, our only hope is the mental health professionals and medical system. Most of the time we do not have good friendships or loving supportive families, and we sure aren't doing a good job of taking care of ourselves properly, or we wouldn't be seeking help in the first place...Having Bipolar or BPD or any other mh issue is not our fault, do our lives deserve to be ruined or wasted in chaos, pain, dysfunction, etc for something we did not cause and cannot control ? We really need the mental health and medical community to see us as humans with a right to a fair chance at life...and not just a labeled patient. Our whole lives depend on it.

I've only known 2 people diagnosed with borderline personality disorder; one male, one female. This is in the UK, where I get the impression that such a diagnosis is more rarely used. The female BPD "sufferer" also has schizoaffective disorder (which begs the question how on earth they were able to diagnose a borderline personality disorder, except that she has severely self-harmed, for many years)... the male patient always seemed on the surface at least to be OK until he started using "mephedrone" better known as meow or 4methylmethcathinone, a designer drug there was a craze for in this country, until it was made illegal in the UK in 2010... he took so much of this stuff he became paranoid and psychotic, but the mental hospital let him out for the afternoon. That afternoon he threw himself under and underground train and died.

So that's what borderline personality means to me. On its own it seems to mean little. Both of the people I knew with it were frequently hospitalized; both used heroin and other addictive drugs. The guy who killed himself was on bipolar medication when he died but he never seemed to have a clear manic episode. I've been psychotically manic and the symptoms are pretty unmistakable. I got told I was bipolar many many times before eventually receiving the diagnosis bipolar schizoaffective.

To me the diagnosis "borderline personality disorder" seems far less insulting than some of the other personality disorders (eg narcissistic personality disorder... even avoidant personality disorder)... reading through the life histories of people with such diagnoses it seems clear they have had SOMETHING going on at other times... the question is... WHAT??!?